Healthcare Provider Details

I. General information

NPI: 1316082712
Provider Name (Legal Business Name): OAK PARK HEALTHCARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N HARLEM AVE
OAK PARK IL
60302-1805
US

IV. Provider business mailing address

2201 MAIN ST
EVANSTON IL
60202-1519
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-5966
  • Fax: 708-848-1257
Mailing address:
  • Phone: 847-905-4026
  • Fax: 847-905-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number004460
License Number StateIL

VIII. Authorized Official

Name: JENNIE SHAN-MARTIN
Title or Position: CONTROLLER
Credential:
Phone: 84790540626